Introduction Exposure to hip joint Indications total hip arthroplasty has lower rate of total hip prosthetic dislocations proximal femur fracture Plane Internervous plane no true internervous plane Intermuscular plane splits gluteus medius distal to innervation (superior gluteal nerve) vastus lateralis is also split lateral to innervation (femoral nerve) Preparation Anesthesia options general spinal Position lateral supine Approach Incision begin 5cm proximal to tip of greater trochanter longitudinal incision centered over tip of greater trochanter and extends down the line of the femur about 8cm Superficial dissection split fascia lata and retract anteriorly to expose tendon of gluteus medius detach fibers of gluteus medius that attach to fascia lata using sharp dissection Deep dissection split fibers of gluteus medius longitudinally starting at middle of greater trochanter do not extend more than 3-5 cm above greater trochanter to prevent injury to superior gluteal nerve extend incison inferior through the fibers of vastus lateralis develop anterior flap anterior aspect of gluteus medius from anterior greater trochanter with its underlying gluteus minimus anterior part of vastus lateralis requires sharp dissection of muscles off bone or lifting small fleck of bone expose anterior joint capsule follow dissection anteriorly along greater trochanter and onto femoral neck which leads to capsule gluteus minimus needs to be released from anterior greater trochanter Structures at Risk Superior gluteal nerve runs between gluteus medius and minimus 3-5 cm above greater trochanter protect by limiting proximal incision of gluteus medius putting a stay suture at the apex of gluteal split leads to Trendelenburg gait pattern Femoral nerve most lateral structure in neurovascular bundle of anterior thigh keep retractors on bone with no soft tissue under to prevent iatrogenic injury